Lyme disease: past, present and future

Infected ticks are crawling toward your patients

by TILKE ELKINS  June 2017

Lyme Alert: You are likely to see far more patients this summer and in the coming months and years suffering from Lyme disease. That’s a big challenge. Diagnosis is difficult and treatment – especially if not begun soon after the patient has been bitten by an infected tick – is controversial.

Blame the growing case load on the warming climate which has resulted in more ticks surviving through our winters and growing populations of birds and rodents that are vectors for the bacteria.

Blame the narrow treatment options on unproven theories on if and how antibiotics work against Lyme when symptoms persist.

Blame all three for increasing patient activism coming soon to a practice near you.

Hunting buddies who coincidentally begin to show symptoms of Parkinson’s disease as the season draws to a close; the star pupil whose reading comprehension suddenly drops; athletes too exhausted to get out of bed; a brilliant scientist diagnosed with frontal dementia in the prime of his career: these are all victims of a looming global epidemic.

Meningopolyneuritis, Garin-Bujadoux syndrome, Bannwarth syndrome, Afzelius’ disease, Montauk Knee, sheep tick fever, or Lyme disease: today, scientists tend to refer to the condition simply as borreliosis, after the bacterial spirochete class of the genus Borrelia that’s transmitted to humans by tick bites. In the US, there are 329,000 new diagnoses reported every year. That’s six times the number of HIV cases, and twice the number of people diagnosed with breast cancer. The Canadian government, on the other hand, reported that
only 841 people were diagnosed with Lyme in 2016 causing many experts to believe that the disease is significantly under reported in this country.

LYME’S LONG HISTORY

Lyme’s relatively recent widespread recognition gives the false impression that the disease is a modern scourge. Until 1975, when a cluster of cases in Old Lyme, Connecticut thought at first to be juvenile rheumatoid arthritis were linked to a similar condition in Europe by the bull’s eye-shaped rash that preceded joint pain, few were aware of the tick-borne illness. Throughout the ‘80s and ‘90s, it was generally assumed to be endemic only in the small region in New England that gave it its current name. But borrelia has been around a lot longer than that. The gut of a 3.9-million-year-old tick preserved in Dominican amber carried large numbers of spirochete-like cells bearing a close resemblance to current borrelia. A 2010 autopsy of Otzi the Iceman, a 5,300-year-old mummy, revealed the presence of borrelia burgdorferi’s DNA sequence, suggesting that the fellow probably struggled with the same achy joints and other symptoms that plague sufferers today.

In 1764 this achiness was aptly described by Scottish Reverend Dr John Walker as “exquisite pain [in] the interior parts of the limbs.” The Reverend said while visiting the Island of Jura off the West Coast of Scotland he’d been bitten by a “worm of a reddish colour and a compressed shape with a row of feet on each side.” Almost 150 years later, the characteristic bull’s eye skin rash that warns of infection was noted by the Swedish dermatologist Arvid Afzelius, who gave the rash the name that has stuck with it: erythema migrans, or ER.

The New World, too, was not without its “reddish worms.” In 1638, New England resident John Jocelyn wrote that the ticks were reported to hang in “infinite numbers” on woodsy undergrowth in summer, lying in wait for the opportunity to “creep into a man’s breeches” and “eat themselves in a short time into the very flesh of a man.” Chances were good that some of them carried borrelia. But it wasn’t until the Old Lyme cases that ticks became actively associated with borreliosis, itself not classified until 1981.

WHY THE SUDDEN SPIKE?

Why the sudden flourishing of the malevolent microbe? North America isn’t its only stomping ground — infection rates are mounting steadily in 80 countries, with particular concentrations in Europe, Mexico, North Africa, and Australia. In England, even London parks host infected ticks. One theory is that the loss of biodiversity has resulted in a glut of animals, including birds and rodents, that are vectors for spirochetes. They transfer the infection to tiny tick larva when the larva have their first blood feeding. The larva then molt into nymphs and go looking for their second blood meal — that is when they are most likely to bite unsuspecting humans.

The nymphs are the size of poppy seeds, nearly impossible to detect even by the scrupulous. The longer they remain attached, the more likely they are to transmit Lyme. Standard wisdom is that infection requires an attachment period of 24 hours or more. That said, some victims report much shorter attachment periods, some as little as six hours.

Last summer’s mouse infestation is a signal of a higher-than-average spread of Lyme this year, say ecologists in eastern Canada and the US. But burgeoning rodent populations aren’t the only reason for the apparently sudden increase in Lyme diagnoses in recent years. Criteria and testing accuracy are also at fault suggest critics of the way the epidemic has been handled. It is true that the Public Health Agency of Canada and the Atlanta-based Center for Disease Control in the US have been slow to come to grips with the inaccuracy of current forms of testing. The ELISA test, most commonly used to diagnosis Lyme, has an inaccuracy rate of 35 to 50%. And while diagnosis guidelines include the presence of a rash following a tick bite, fewer than 50% of Lyme patients remember either the bite or a rash. The Global Lyme Alliance claims that owing to diverse nature of the symptoms and short comings in testing, only 1 in 10 cases are officially reported.

Diagnosis is not the only controversy. More significant is the question of prolonged symptoms which persist long after treatment has ended. For many patients — the lucky ones — a course of antibiotics seems to clear up symptoms for good. But for perhaps as many as 40%, symptoms persist, especially if antibiotic treatment is delayed. The large range of presenting symptoms can make an accurate diagnosis difficult and delays in the start of a course of antibiotics is common. Lyme has been called “the new great imitator” due to its resemblance to fibromyalgia, chronic fatigue syndrome, multiple sclerosis, ALS, Parkinson’s, Alzheimer’s, bipolar disorder, and a host of other neurological disorders. The consequences of a misdiagnosis can be serious, like those of syphilis, another spirochetes infection which plagued earlier generations. Untreated borreliosis eventually gravitates to the brain and causes neuropsychiatric disease.

Due to the difficulty of obtaining a positive test result for Lyme, especially once the disease has progressed for years, scores of patients with Lyme-like symptoms have been sent home without diagnosis or treatment. Some medical opinion suggests these patients are suffering from Post Treatment Lyme Disease (PTLD), caused not by the presence of a borreliosis infection, but by residual damage to tissues and the immune system and do not consider it a chronic condition. On the other hand, there are physicians who treat these continuing symptoms with a combination of long-term antibiotics and nutritional supplements despite regulatory cautions about extended antibiotic treatment, who report positive patient results.

PROTECTIVE BIOFILM?

In 2016 a double-blind placebo-controlled Dutch study into the effects of long-term antibiotic treatment for Lyme disease failed to show that there were any signs of reduced symptoms following prolonged antibiotic use.

So, who’s right? A possible reason for the marked difference of opinion between practitioners is suggested by another peer-reviewed study published recently in the European Journal of Microbiology. That paper suggests that borrelia spirochetes can “hide” from antibiotic treatment by creating a biofilm around the bacteria, making it up to 1,000 times more resistant to antibiotics than other bacteria. Doctors who say they have successfully treated lingering Lyme disease with antibiotics may be finding ways to penetrate this biofilm. One Arizona center for Lyme treatment claims that its treatment “strip[s] the anion polysaccharide matrix layer of the biofilm while exposing the infection to oxygen-rich saturation and deliver[ing] targeted antibiotics all in one sequence in order to penetrate into the cell wall.”

Protesters clad in neon green t-shirts and pinned with green ribbons have demanded changes in how Lyme is defined, diagnosed and treated in cities the world over. And while controversy continues to surround Lyme issues on all fronts, there is one thing everyone seems to agree on: the epidemic is building, and it is building fast. The challenge is to find better diagnostic tools and to accelerate research into what remains a mysterious and confounding disease for the GP/FPs on the front line and for their increasingly frantic patients.

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Borrelia bacteria are stealth pathogens that can dampen our immune response and hide intracellularly in immune protected locations. They have several different forms and have a very slow 21-23 hour reproduction rate. Success in treatment of this complex infection, if started late depends on the length of treatment with several antimicrobials (for the different forms) used concomitantly and not on the dosage of a single bacteriostatic antibiotic used for brief periods of 3 months or less. The Dutch study used a single antibiotic that is useful only in the early stages of the disease and ended at 3 months. A simple case of late LD usually takes 1.5 years - 2 years to treat. They were just looking for another headline to say that long term antibiotics don't work. Antibiotic resistance is a hospital phenomenon associated with high dose short term I.V. antibiotics and not long term oral treatment used for Lyme disease. We can't even kill this bug in a test tube with a single antimicrobial. It is like pretending to kill dandelions with the lawnmower. Evidenced based means you have to evaluate all the evidence not just the things you agree with while rejecting everything else. All decisions about Lyme disease are made behind closed doors and constitute dogma.

For further Information on Lyme disease:
The Canadian Lyme disease Foundation (https://canlyme.com) web site has up-to-date sections on prevention, symptoms (https://canlyme.com/lyme-basics/symptoms/), diagnosis, treatment and news for physicians (https://canlyme.com/?s=For+physicians&lang=en). Other sources of important information are the peer reviewed and published 2014 International Lyme and Associated Diseases (ILADS) guidelines on Lyme disease management: http://www.tandfonline.com/doi/full/10.1586/14787210.2014.940900
There is an excellent free online accredited CME accredited course [CFPC] on Lyme disease at https://www.lymecme.info